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FACILITATING IMPROVED END-OF-LIFE CARE
Session 258, February 14, 2019
Allison L. Weathers, MD, FAAN
Assoc. CMIO, Cleveland Clinic
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Allison L. Weathers, MD
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Background
Why is this conversation so essential?
Cleveland Clinic’s journey
Our recommendations
Our approach
Our lessons learned
Your journeys
Where are you in the Advance Care Planning (ACP) journey?
How did you get there team, project plan, process?
What did you wish you had known starting out?
Advice for others?
What do we want EHR vendors to realize?
Agenda
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Identify the necessary roles that should
comprise an ACP module implementation
project team
Formulate an ACP module implementation
project plan, including timelines, deliverables
and training and communication needs
Recognize what components are necessary to
include in an ACP module and how to take into
account local and state regulatory and legal
requirements in their design
Learning Objectives
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Source: NEJM Nov 30, 2017 and NY Times
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“It always seems too early until it is
too late”
60% of people say that making sure their family is not
burdened by tough decisions is “extremely important”
But 56% have not communicated their end-of-life
wishes
90% of people say that talking to their loved ones about
end-of-life care is important
But only 27% have actually done so
80% of people say that if seriously ill they would want to
talk to their physicians about end-of-life care
But only 7% report having had an end-of-life
conversation with their physicians
Source: The Conversation Project National Survey 2013, CDC
Theconversationproject.org
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Cleveland Clinic Center for End of Life (EOL) Care
Advance Directives
(AD) for every adult
Goals of Care (GOC)
for seriously ill
Book Clubs
EOL GR
“The Pause”
Respect patient’s
preferences
Foster caregivers’
resilience
Improve family
experience
GOC Meeting
Standardization
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Cleveland Clinic Recommends:
Healthy
Non-seriously ill
Seriously ill
Non-critical
Critical
Dying
Advance Directives
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Cleveland Clinic Recommends:
Healthy
Non-seriously ill
Seriously ill
Non-critical
Critical
Dying
Goals of care in the EHR
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Partnership between IT and operational
stakeholders (End-of-Life Center)
Met regularly for 9 months
Heavily utilized subcommittees
• Started with our vendors base build
Tried to adhere to it wherever possible
Justified it when we couldn’t
Validated all decisions with legal team
Our Approach
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Project Team
IT
Center for End of Life
Pall Med
Bioethics
Oncology
Nursing
Legal, HIM, Compliance, Risk
Case management
Patient Experience
Center for Healthcare Communication
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Advance Care Planning Activity Needs
Visible from all contexts
Accommodate multiple types of providers
Provide conversation guide
Enhance
Multidisciplinary communication
Coordination of care
Quantifiable for research and quality
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ACP Activity Needs
One single location for
Advance Directives
Spirituality
Prognosis
Understanding
Goals of care/values/wishes
Collaboratively plan
Code status discussion
All resultant documentation
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Challenges
Legal, compliance, ethical concerns raised
Health Care Agent
Differing policies/regulations across the
health system
Legally vs non-legally binding documents
New note type needed
Getting the word out
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Our Build
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Header
© 2019 Epic Systems Corporation. Used with permission.
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Surrogate Decision Makers
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Surrogate Decision-Makers
© 2019 © 2019 Epic Systems Corporation. Used with permission
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ACP Documents
© 2019 Epic Systems Corporation. Used with permission.
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OTHER ACP
DOCUMENTS
Not yet vetted or invalid
ACP Documents
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Care Manager AD Assessment
© 2019 Epic Systems Corporation. Used with permission.
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Spirituality
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Goals of Care
©© 2019 Epic Systems Corporation. Used with permission.
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Goals of Care - Prognosis
© Systems © 2019 Epic Systems Corporation. Used with permission.
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Goals of Care - Understanding
© 2019
© 2019 Epic Systems Corporation. Used with permission.
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Goals of Care Wishes and Values
© 2019 Epic Systems © 2019 Epic Systems Corporation. Used with permission.
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Goals of Care Wishes and Values
Systems © 2019 Epic Systems Corporation. Used with permission.
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Goals of Care Wishes and values
© 2019 Epic Systems Corporation. Used with permission.
Systems © 2019 Epic Systems Corporation. Used with permission.
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Goals of Care Shared Plan
© 2019 Epic Systems Corporation. Used with permission.
Systems © 2019 Epic Systems Corporation. Used with permission.
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Code Status
Systems © 2019 Epic Systems Corporation. Used with permission.
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Periprocedural Code Status Discussion
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ACP Notes
© 2019 Epic Systems Corporation. Used with permission.
© 2019 Epic Systems Corporation. Used with permission.
© 2019 Epic Systems Corporation. Used with permission.
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Issues with right roles/contexts seeing the
activity
Even if did have it, couldn’t find it
Even if can find it, aren’t using it
Should we try to have it be all things to all
people?
Our Challenges Post Go-Live
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How do we get providers to use the tools?
Patient driven better integration with the
patient portal
Perinatal preferences for pregnant women
Jehovah’s Witnesses preferences
Organ donation support
Our journey is far from over…
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Where are you in your ACP journey?
How did you get there?
team, project plan, process
How did you communicate / educate and what
have you done to get buy-in and adoption?
Have you been successful?
What do you wish you had known starting out?
Advice for others?
What do we want EHR vendors to realize?
Essential Conversation
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Even if I am dying,
until I actually die,
I am still living.
Paul Kalanithi
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Acknowledgements
Silvia Perez-Protto, MD, MS
Director, CC End-of-Life Center
Ellie Blogna
Analyst, ITD
Diane Petersen
Administrator, CC End-of-Life Center
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Thank you for your participation today
Please complete the online session evaluation
Please contact me with any further questions
Allison Weathers
weathea@ccf.org
216-310-9612
@AlWeathersMD
Questions